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In this episode, we explore the complexities of the doctor-patient relationship in a challenging setting with our guest, Joseph Baskin, a jailhouse psychiatrist. Joseph shares his experiences working with inmates who suffer from serious mental illnesses like schizophrenia and severe bipolar disorder. These individuals often lack insight into their own conditions, making the traditional doctor-patient contract difficult to establish. We delve into the unique challenges of assessing and treating patients in jail, where factors like intoxication, substance abuse, and withdrawal complicate their mental health.

Joseph Baskin is a psychiatrist.

He discusses the KevinMD article, “The unspoken contract between doctors and patients: Navigating mental illness in the jail setting.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Joseph Baskin. He is a psychiatrist, and today’s KevinMD article is “The unspoken contract between doctors and patients: navigating mental illness in a jail setting.” Joseph, welcome to the show.

Joseph Baskin: Thank you so much for having me.

Kevin Pho: We’ll talk about your article in a little bit. First off, let’s briefly share your story and journey.

Joseph Baskin: Absolutely. So I’m from Ohio originally, left for about 20 years to do a lot of training. Returned from medical school here in Columbus, Ohio, then did actually a year of general surgery, was thinking about doing plastic surgery, wanted to stay more with patients, so switched into psychiatry in the Northeast. Then did additional training in psychotherapy and in forensic psychiatry.

So I’ve been around a little bit. I was in private, kind of work with the Cleveland Clinic Foundation about nine years, specializing in suicide, and then I’ve been at the jail for about the past five years here in Cuyahoga County. That’s the county where Cleveland is.

Kevin Pho: All right, so how did you find yourself working in a prison setting?

Joseph Baskin: First job out of residency was in a prison, actually, in Massachusetts, a place called Bridgewater State Hospital. Massachusetts has an unusual system, or they used to, where people off the street could be mingled with people from max level prisons. It was a place where psychiatry did a lot of its work. We had chronic people there, acute people there, and I fell in love with forensic psychiatry, correctional medicine, back then. Took me a little while to get back to it, but that’s why I like doing what I do.

Kevin Pho: All right, so tell me a typical day in the setting.

Joseph Baskin: Well, one of the things is that there isn’t a typical day, and that’s probably one of the reasons I like it so much. So, differentiating a jail from a prison. Prison is where they go once they are found guilty, right? They’re sentenced, they’re usually state facilities. Jail is where somebody comes right off the street. There they’re a pretrial detainee, meaning they haven’t been found guilty. Most of the time, sometimes they’re there on violations, things of that nature, but for the most part they’re not guilty, they’re coming into jail.

And because of hospitals being, you know, we’re no longer hospitalizing the psychiatric population, we get a lot of people who slip through the cracks, right? So if a person is, let’s say, mentally unstable, but they’re calm and they go to the ER, they may not get hospitalized. They’re not suicidal, they’re not aggressive, but we know they need treatment, but we just don’t have a place to put them. So they end up, low-level charges, sometimes high-level charges, they end up in jail.

And what’s happened is jails are the de facto largest supplier of mental health in the country. And that was one of the reasons that I really wanted to get here. I really enjoy the acuity of it. The pathology is extensive. I see sicker people than I’ve ever seen any time in my career. I don’t have the courts behind me, meaning I can’t always forcibly medicate, because there’s no provision for that in the jail. But it makes me develop rapport, it makes me get to know them and try to understand them, to see if I can get their trust, trust being a very difficult thing to get inside of jail, as you might imagine.

Kevin Pho: So let’s talk about your KevinMD article, “The unspoken contract between doctors and patients: navigating mental illness in a jail setting.” So for those who didn’t get a chance to read your article, tell us what it’s about.

Joseph Baskin: Really it’s an introduction to what it’s like to be working with a population where you are not always aligned. In other words, a person comes to a doctor, as a standard doctor-patient contract, it’s, I’m going to tell you everything as the patient, I’m going to be as honest as I can, because with that information you are going to do everything you can to provide me with a good diagnosis and a good treatment. And where that falls apart is where my goals and the patient’s goals are not aligned.

So a guy comes into, it could be a woman, we have women as well in the jail, a person comes into the jail and they are, first of all, upset. They’re in shock, because obviously they were on the street one minute and they’re arrested the next. They don’t know who to trust, they don’t know if what they’re going to say is going to be held against them, and they are oftentimes under the influence or withdrawing.

So it really becomes a question of understanding the person that I’m seeing, getting a sense of how we can help them, and more importantly, how can I get to know them enough so that they can develop enough trust in me, so that I can give them something that can get them better. They have to know that I’m looking out for their best interest, as opposed to either just marking my time, right? In other words, the idea being that if you can’t hack it in the real world, you do it in jail. So there’s some mistrust there. It’s about what you do when what you want to do for them is not necessarily how they’re going to perceive what you want to do for them. One of the great challenges of working in a jail.

Kevin Pho: So what are some ways that you do to build trust in this patient population?

Joseph Baskin: Very good question. So there’s a few things. Number one, and I would say this applies anywhere in medicine, I always follow through with what I say I’m going to do. And that might seem like an easy thing and a very common sense thing, but oftentimes when you’re dealing with somebody who can be violent or can be aggressive, there’s a tendency to want to tell them what you think they want to hear. I want to extricate myself as the physician from the situation. So especially in the ER, that’s something that happens. You’re going to hospitalize the guy against his will, you don’t tell him that, you just kind of tell him whatever you think he wanted to hear, so that you can get through the situation unscathed.

And there’s a perception, especially amongst the antisocial population, that that’s sometimes the best way to go about it. What I do is, I tell them genuinely what I can, I tell them upfront what I can and can’t do, and I lay it out straight, meaning I don’t tell them positive things when there’s nothing positive to tell them. If there’s something negative, I’ll tell them something negative. And I think that if you feel it, if you feel that genuineness, they perceive it.

Something I’ve noticed, people with very bad character pathology, everybody in medicine recognizes the borderline personality, right, the antisocial personality. Those two personalities particularly, I feel, have almost a sixth sense of when somebody doesn’t care about them. And so if you’re speaking to them as the doctor and they know that you don’t believe them, or you don’t think that they’re worth taking the time for, they pick up on that, probably because of developmental issues, the way that they’ve been perceived their whole lives.

So I make sure that when I go see somebody of this ilk, all right, of this nature, of this temperament, I tell myself it’s not personal, whatever it is. I really get myself to a place where I can see their perspective and I try to help them. So I’m genuine, I’m sincere, I don’t blow smoke up their rear, meaning I don’t tell them things that aren’t going to happen, are not going to be true. And then I follow through.

And this is where seeing people more than once especially helps me, because once they’ve seen that I’ve done that, that I follow through, that I’ll tell them what I’ll tell them but I’ll follow through, even if it’s the littlest thing. And sometimes I’ll tell them, I’m going to find out for you and I’m going to get back to you, even if to tell you that I didn’t find anything out, I’m sorry I couldn’t find anything out.

And I think that’s probably not hard for most physicians, right? Most physicians go into the field, they want to help people. And it’s only those misunderstandings, or those perceptions that something bad will happen, that throws them from that stance. So they’re really common sense, but it’s knowing how to best approach the situation.

There are some situations where I walk away, right? If a person’s psychotic and aggressive, there’s no amount of discussion that I’m going to have that’s going to make a difference. Then it’s about getting them the treatment that they need as best I can, and then if I can’t, then it’s in helping the rest of the jail manage this difficult patient.

Kevin Pho: One of the things that you said appealed to you about this setting was the acuity of a lot of the cases that you see. Sometimes I can only imagine that you have very limited information on a lot of the people that you see. How do you best treat them in these acute settings, given the paucity of information that I can only imagine you receive in this setting?

Joseph Baskin: That’s a great question. We call it a low-information setting, exactly like you’re describing it, because they aren’t forthcoming. Great thing is, all major hospitals in the area, in the Cleveland area, are all on Epic now, so they all have the same electronic medical record. That helps some.

I would say presentation makes a big difference, and time. My great sort of elucidator of what’s going on is time. Most of the instances, a person will be here long enough, as opposed to the hospital where they get discharged sometimes after two, three days. Here they’ll be here long enough where time will show me what’s going on.

Now, it’s an artificial setting, right? They’re getting three meals a day, they’re locked up, they’re stressed, they’re under strain because they don’t know what’s going to happen, most of the time they feel like it’s been unjust, it’s unfair. But I can get a sense, with rare exception, I get a sense of what’s going on. Sometimes it’s not clear how much is character, how much is psychosis, how much is mania, how much is depression, but usually it becomes clear.

Kevin Pho: So what is a mark of success in the jail setting? How do you know that you’re making a difference and moving the needle?

Joseph Baskin: Our eyes will tell us, right? In other words, we see improvement, we see coherency, engagement, fewer violent actions, compliance with treatment plans. We have a lot of connection with the community mental health centers and the courts, so we’re always engaging with them about things we can do to reduce recidivism, to reduce return to the jail, especially for those that we know, but for the mental illness, they would not be here, they would be treated in the community rather than in jail.

There isn’t, I don’t have good long-term data, it’s a little bit hard to get to for different reasons. One of the things that gets me up every day is knowing that at that moment that I see somebody, possibly I have an impact on them, much like the old chaos theory, the butterfly flapped his wings in India and there’s a monsoon in the Amazon. That at some point, if I’m just flipping something, if I’m doing a little something, maybe the ripples will be extended. But I don’t always know.

Kevin Pho: How long would a typical patient in a jail setting be there for? Give us a sense. Are you talking about you’ll just see them one time, are they there for days, weeks? So in general, how long are patients there for?

Joseph Baskin: So a person comes into the jail, the length of stay is skewed, because most of them are one to three days and then they’re out, and some of them stay for four to five years awaiting their case, right? So the great vast majority, I would say especially the sicker ones, I have more time than less, meaning at least two to six weeks, sometimes longer.

And that’s because if they’re really mentally ill, either we’re holding them until they can get to the hospital and be restored to competency, right, or we’re holding them until a plan can be put in place in the community that the court will accept, and then they’re released into the community with an extensive mental health plan in place. So we’re talking about weeks.

Kevin Pho: And what are some of the common behavioral health conditions that you would treat in that setting?

Joseph Baskin: Psychosis is a big one. So schizophrenia, schizoaffective disorder, substance-induced psychosis, meaning people who are outside of reality, right? They’re either delusional, they’re actively hallucinating, those kinds of things. I see manics.

I’ll tell you something I don’t see, which is interesting. If I see five people in a year with real major depressive disorder, that’s a lot. So I don’t see, it’s interesting, in prison you see more depression. Here I see a lot of adjustment reactions, a tremendous amount of post-traumatic stress, whether it’s the real diagnosis or just the effects of trauma over time. It’s just myriad, and a lot of substance. But it’s the serious, severe mental illness, the schizophrenia, the bipolar disorder. See a lot of that.

Kevin Pho: So from a substance use standpoint, are there things that you can do in the jail setting to help with that aspect?

Joseph Baskin: Absolutely. We do in the jail, you know, MAT, we do medication-assisted treatment, that’s the Subutex. We’re starting to get into Sublocade, that’s the injectable form, that’s the long form. We do Vivitrol, we do withdrawal protocols for benzodiazepines, for alcohol, for opiates. We identify, we have a whole addiction medicine program, counseling and things of that nature.

Less interventions for things like meth, PCP, and we see a lot of those too. And those, when you talk about psychosis, meth and PCP are your two biggest culprits, with that along with K2. That’s a little bit less so, though, now.

Kevin Pho: For those residents and medical students who may be listening to your podcast and may not be familiar with practicing medicine in a jail setting, what kind of questions should they ask themselves to see whether this is something that would be in their interest?

Joseph Baskin: That’s another great question. I would say this: if a person thinks that it’s something they’d be interested in, it probably means that they are. There’s probably about 20 percent of us who are insane, right, by birth or something, some sort of condition, where we enjoy it for a variety of different reasons. So it’s always interesting, right? So never bored. There’s a real need, and there’s a real feeling like you’re doing something with great meaning when you make an intervention.

If a person doesn’t have a problem being behind a locked door, right, if they don’t have a problem with their comings and goings being controlled by someone else, that may sound like a small thing, but you go in and all of a sudden you can’t leave. For some people that causes a little bit of panic. But I think if a person has a sense that they’re passionate about that kind of thing, they probably do, and if they seek it out and it has that feel to them, then they’ll get great satisfaction out of it.

Kevin Pho: Any concern about your own personal safety whenever you’re talking to people in jails about behavioral health conditions?

Joseph Baskin: The short answer is no. The long answer is, as a psychiatrist I am my first line of defense, meaning I have to assess, first of all, what am I dealing with, how to extricate myself, how to identify early and extricate. I certainly am better at it each year that goes by. I am surrounded by security and I know how to interact with that security, so I don’t take matters into my own hands, and I don’t fancy myself as somebody in security, if that makes sense. In other words, I do psychiatry, they do security. I leave them to that and I do what I do.

And so I don’t fear for that, but that’s a good point, when somebody thinks about it. If they’re worried about their safety, I don’t know that it’s great for somebody like that, and I think once they get in they can see that it’s probably better than they thought, especially with all the security. But I’m fortunate, I haven’t been assaulted, and so I continue to operate with a certain amount of, I’m here to help, and that should alleviate any sort of tension with those who aren’t psychotic. And if they’re psychotic, I identify and treat accordingly.

Kevin Pho: So tell us a particularly rewarding case. It could be hypothetical, but what’s one story that you could tell us where you really moved the needle for that particular patient?

Joseph Baskin: There’s a lot of different stories of that nature. I would say when somebody comes in and they refuse to take medications, and I am patient with them, I do a real soft sell, I tell them it’s their choice, and over time I get them to try it at least once. I tell them, look, if you don’t like it you’re not going to take it again, there’s nothing lost, right? I get nothing out of it. Give it a try and see what happens. And with a certain regularity I will get people to try it, and then I start to see improvement.

Every once in a while I can prevent somebody from having to go to the hospital for a restoration, meaning they have to be transported to a hospital, they have to have an evaluation, they get treatment. It’s not necessary if they’re already in treatment. So I repetition the court to evaluate the person, do they still need that. And that’s a rewarding thing. That saves a lot of money, it saves the person, and they get better.

Kevin Pho: We’re talking to Joseph Baskin. He’s a psychiatrist. Today’s KevinMD article is “The unspoken contract between doctors and patients: navigating mental illness in a jail setting.” Joseph, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Joseph Baskin: I would like you to know that if any of this sounds interesting, pursue it. It’s a great career, it’s very, very interesting, endlessly interesting and endlessly rewarding. And put aside any ideas about your risk. Go and see what it feels like. It’s definitely worth it.

Kevin Pho: And how can people reach you?

Joseph Baskin: I have a website, JosephBaskin.com, and I’m on Instagram.

Kevin Pho: All right. Joseph, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Joseph Baskin: Thank you very, very much. Great.